Skip to main content
SpringerLink
Log in

Clostridium difficile and the Disease It Causes

  • Protocol
  • First Online:
Clostridium difficile

Part of the book series: Methods in Molecular Biology ((MIMB,volume 646))

Abstract

Clostridium difficile is a spore-forming, toxin-producing, anaerobic bacterium abundant in soils and water. Frequent and early colonization of the human intestinal flora is common and often asymptomatic. Antimicrobials given commonly disrupt the intestinal microflora and through proliferation in colon and production of toxin A and B it precipitates C. difficile infection (CDI). The enterocytic detachment and bowel inflammation provoke C. difficile-associated diarrhoea (CDAD) sometimes developing into severe pseudomembranous colitis (PMC) and paralytic ileus. Infection is acquired from an endogenous source or from spores in the environment, most easily facilitated during hospital stay. In the elderly, comorbidity, hospitalization and antimicrobial treatment present as major risk factors and the slow recolonization of the normal flora likely responsible for single or multiple recurrences of CDI (25–50%) post therapy. The key procedure for diagnosis is toxin detection from stool specimens and sometimes in combination with culture to increase sensitivity. In mild cases stopping the offending antimicrobial will lead to resolution (25%) but standard therapy still consist of either oral metronidazole or vancomycin. Alternative agents are presently being developed and fidaxomicin, as well as nitrothiazolide are promising. Furthermore, host factors like low antitoxin A levels in serum relates to increased risk of recurrence and small numbers of patients have received immunoglobulin with good results. An immunogenic toxoid vaccine has been developed and human colostrum rich in specific secretory Ig A also support the future use of immunotherapy. Today we experience a tenfold increase of CDI incidence in the western world and both epidemics and therapeutic failure of metronidazole is contributing to morbidity and mortality. The current epidemic of the C. difficile strain NAP1/027 emerging in 2002 in Canada and the USA has now spread to most parts of Europe and virulence factors like high toxin production and sporulation challenge the therapeutic situation and cause great concern among infection control workers. Excessive use of modern fluoroquinolones is thought to play an important role in facilitating this epidemic since NAP1/027 was shown to have acquired moxifloxacin resistance compared to historical strains of the same genotype. Both the current epidemic like this and other local outbreaks from resistant or virulent strains warrant culture to be routinely performed enabling susceptibility testing and typing of the pathogen. Genotyping is most commonly done today by pulse-field gel electrophoresis (PFGE) or PCR ribotyping but multilocus variable-number tandem-repeat analysis (MLVA) seems promising. Epidemiological surveillance using all these tools will help us to better understand the global spread of C. difficile.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Protocol
USD 49.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 159.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Novogrudsky A and Plaut AG. (2003) The bacterial flora of the healthy gastrointestinal tract: colonization of the human colon. In: Yamada T, ed., Gastroenterology, 4th ed., Lippincott Williams & Wilkins, Philadelphia, 584–585.

    Google Scholar 

  2. Savage DC. (1981) The microbial flora in the gastrointestinal tract. Prog Clin Biol Res 77, 893–908.

    CAS  PubMed  Google Scholar 

  3. Mai V and Morris JG, Jr. (2004) Colonic bacterial flora: changing understandings in the molecular age. J Nutr 134, 459–464.

    CAS  PubMed  Google Scholar 

  4. Evaldson G, Heimdahl A, Kager L and Nord CE. (1982) The normal human anaerobic microflora. Scand J Infect Dis Suppl 35, 9–15.

    CAS  PubMed  Google Scholar 

  5. Vollaard EJ and Clasener HA. (1994) Colonization resistance. Antimicrob Agents Chemother 38, 409–414.

    Article  CAS  PubMed  Google Scholar 

  6. Al Saif N and Brazier JS. (1996) The distribution of Clostridium difficile in the environment of South Wales. J Med Microbiol 45, 133–137.

    Article  CAS  PubMed  Google Scholar 

  7. Hatheway CL. (1990) Toxigenic clostridia. Clin Microbiol Rev 3, 66–98.

    CAS  PubMed  Google Scholar 

  8. Murray PR. (2005) Clostridium. In: Murray PR, Rosenthal KS and Pfaller MA, eds., Medical Microbiology, 5th ed., Mosby, St. Louis.

    Google Scholar 

  9. Debard N, Sierro F and Kraehenbuhl JP. (1999) Development of Peyer’s patches, follicle-associated epithelium and M cell: lessons from immunodeficient and knockout mice. Semin Immunol 11, 183–191.

    Article  CAS  PubMed  Google Scholar 

  10. Kelly CP, Pothoulakis C and LaMont JT. (1994) Clostridium difficile colitis. N Engl J Med 330, 257–262.

    Article  CAS  PubMed  Google Scholar 

  11. Eglow R, Pothoulakis C, Itzkowitz S, et al. (1992) Diminished Clostridium difficile toxin A sensitivity in newborn rabbit ileum is associated with decreased toxin A receptor. J Clin Invest 90, 822–829.

    Article  CAS  PubMed  Google Scholar 

  12. Tullus K, Aronsson B, Marcus S and Mollby R. (1989) Intestinal colonization with Clostridium difficile in infants up to 18 months of age. Eur J Clin Microbiol Infect Dis 8, 390–393.

    Article  CAS  PubMed  Google Scholar 

  13. Langley JM, LeBlanc JC, Hanakowski M and Goloubeva O. (2002) The role of Clostridium difficile and viruses as causes of nosocomial diarrhea in children. Infect Control Hosp Epidemiol 23, 660–664.

    Article  PubMed  Google Scholar 

  14. Viscidi R, Laughon BE, Yolken R, et al. (1983) Serum antibody response to toxins A and B of Clostridium difficile. J Infect Dis 148, 93–100.

    Article  CAS  PubMed  Google Scholar 

  15. Kelly CP and LaMont JT. (1998) Clostridium difficile infection. Annu Rev Med 49, 375–390.

    Article  CAS  PubMed  Google Scholar 

  16. Wilcox M and Minton J. (2001) Role of antibody response in outcome of antibiotic-associated diarrhoea. Lancet 357, 158–159.

    Article  CAS  PubMed  Google Scholar 

  17. Shim JK, Johnson S, Samore MH, Bliss DZ and Gerding DN. (1998) Primary symptomless colonisation by Clostridium difficile and decreased risk of subsequent diarrhoea. Lancet 351, 633–636.

    Article  CAS  PubMed  Google Scholar 

  18. Leung DY, Kelly CP, Boguniewicz M, Pothoulakis C, LaMont JT and Flores A. (1991) Treatment with intravenously administered gamma globulin of chronic relapsing colitis induced by Clostridium difficile toxin. J Pediatr 118, 633–637.

    Article  CAS  PubMed  Google Scholar 

  19. Johnson S, Sypura WD, Gerding DN, Ewing SL and Janoff EN. (1995) Selective neutralization of a bacterial enterotoxin by serum immunoglobulin A in response to mucosal disease. Infect Immun 63, 3166–3173.

    CAS  PubMed  Google Scholar 

  20. Kyne L, Warny M, Qamar A and Kelly CP. (2000) Asymptomatic carriage of Clostridium difficile and serum levels of IgG antibody against toxin A. N Engl J Med 342, 390–397.

    Article  CAS  PubMed  Google Scholar 

  21. Corthier G, Muller MC, Wilkins TD, Lyerly D and L’Haridon R. (1991) Protection against experimental pseudomembranous colitis in gnotobiotic mice by use of monoclonal antibodies against Clostridium difficile toxin A. Infect Immun 59, 1192–1195.

    CAS  PubMed  Google Scholar 

  22. Warny M, Vaerman JP, Avesani V and Delmee M. (1994) Human antibody response to Clostridium difficile toxin A in relation to clinical course of infection. Infect Immun 62, 384–389.

    CAS  PubMed  Google Scholar 

  23. Khan MY and Hall WH. (1966) Staphylococcal enterocolitis – treatment with oral vancomycin. Ann Intern Med 65, 1–8.

    CAS  PubMed  Google Scholar 

  24. Tedesco FJ, Barton RW and Alpers DH. (1974) Clindamycin-associated colitis. A prospective study. Ann Intern Med 81, 429–433.

    CAS  PubMed  Google Scholar 

  25. Larson HE, Parry JV, Price AB, Davies DR, Dolby J and Tyrrell DA. (1977) Undescribed toxin in pseudomembranous colitis. Br Med J 1, 1246–1248.

    Article  CAS  PubMed  Google Scholar 

  26. Rifkin GD, Fekety R and Silva J. (1978) Neutralization by Clostridium sordellii antitoxin of toxins implicated in clindamycin-induced cecitis in the hamster. Gastroenterology 75, 422–424.

    Google Scholar 

  27. Bartlett JG, Chang TW, Gurwith M, Gorbach SL and Onderdonk AB. (1978) Antibiotic-associated pseudomembranous colitis due to toxin-producing clostridia. N Engl J Med 298, 531–534.

    Article  CAS  PubMed  Google Scholar 

  28. McFarland LV, Surawicz CM, Greenberg RN, et al. (1995) Prevention of beta-lactam-associated diarrhea by Saccharomyces boulardii compared with placebo. Am J Gastroenterol 90, 439–448.

    CAS  PubMed  Google Scholar 

  29. Gerding DN. (1989) Disease associated with Clostridium difficile infection. Ann Intern Med 110, 255–257.

    CAS  PubMed  Google Scholar 

  30. Norén T, Åkerlund T, Bäck E, et al. (2004) Molecular epidemiology of hospital-associated and community-acquired Clostridium difficile infection in a Swedish county. J Clin Microbiol 42, 3635–3643.

    Article  PubMed  Google Scholar 

  31. Bartlett JG. (1992) Antibiotic-associated diarrhea. Clin Infect Dis 15, 573–581.

    Article  CAS  PubMed  Google Scholar 

  32. Boyce JM and Havill NL. (2005) Nosocomial antibiotic-associated diarrhea associated with enterotoxin-producing strains of methicillin-resistant Staphylococcus aureus. Am J Gastroenterol 100, 1828–1834.

    Article  PubMed  Google Scholar 

  33. Pituch H, van den Braak N, van Belkum A, et al. (2002) Characterization of Clostridium perfringens strains isolated from Polish patients with suspected antibiotic-associated diarrhea. Med Sci Monit 8, BR85–BR88.

    PubMed  Google Scholar 

  34. Cohen SH, Shetab R, Tang-Feldman YJ, Sarma P, Silva J, Jr. and Prindiville TP. (2006) Prevalence of enterotoxigenic Bacteroides fragilis in hospital-acquired diarrhea. Diagn Microbiol Infect Dis 55, 251–254.

    Article  CAS  PubMed  Google Scholar 

  35. Danna PL, Urban C, Bellin E and Rahal JJ. (1991) Role of candida in pathogenesis of antibiotic-associated diarrhoea in elderly inpatients. Lancet 337, 511–514.

    Article  CAS  PubMed  Google Scholar 

  36. Hovius SE and Rietra PJ. (1982) Salmonella colitis clinically presenting as a pseudomembranous colitis. Neth J Surg 34, 81–82.

    CAS  PubMed  Google Scholar 

  37. Sullivan NM, Pellett S and Wilkins TD. (1982) Purification and characterization of toxins A and B of Clostridium difficile. Infect Immun 35, 1032–1040.

    CAS  PubMed  Google Scholar 

  38. Just I, Fritz G, Aktories K, et al. (1994) Clostridium difficile toxin B acts on the GTP-binding protein Rho. J Biol Chem 269, 10706–10712.

    CAS  PubMed  Google Scholar 

  39. Just I, Selzer J, Wilm M, von Eichel-Streiber C, Mann M and Aktories K. (1995) Glucosylation of Rho proteins by Clostridium difficile toxin B. Nature 375, 500–503.

    Article  CAS  PubMed  Google Scholar 

  40. Just I, Wilm M, Selzer J, et al. (1995) The enterotoxin from Clostridium difficile (ToxA) monoglucosylates the Rho proteins. J Biol Chem 270, 13932–13936.

    Article  CAS  PubMed  Google Scholar 

  41. Pechine S, Janoir C, Boureau H, et al. (2007) Diminished intestinal colonization by Clostridium difficile and immune response in mice after mucosal immunization with surface proteins of Clostridium difficile. Vaccine 25, 3946–3954.

    Article  CAS  PubMed  Google Scholar 

  42. von Eichel-Streiber C, Boquet P, Sauerborn M and Thelestam M. (1996) Large clostridial cytotoxins – a family of glycosyltransferases modifying small GTP-binding proteins. Trends Microbiol 4, 375–382.

    Article  Google Scholar 

  43. Triadafilopoulos G, Pothoulakis C, O’Brien MJ and LaMont JT. (1987) Differential effects of Clostridium difficile toxins A and B on rabbit ileum. Gastroenterology 93, 273–279.

    CAS  PubMed  Google Scholar 

  44. Price AB and Davies DR. (1977) Pseudomembranous colitis. J Clin Pathol 30, 1–12.

    Article  CAS  PubMed  Google Scholar 

  45. Lyerly DM, Barroso LA, Wilkins TD, Depitre C and Corthier G. (1992) Characterization of a toxin A-negative, toxin B-positive strain of Clostridium difficile. Infect Immun 60, 4633–4639.

    CAS  PubMed  Google Scholar 

  46. Libby JM, Jortner BS and Wilkins TD. (1982) Effects of the two toxins of Clostridium difficile in antibiotic-associated cecitis in hamsters. Infect Immun 36, 822–829.

    CAS  PubMed  Google Scholar 

  47. Popoff MR, Rubin EJ, Gill DM and Boquet P. (1988) Actin-specific ADP-ribosyltransferase produced by a Clostridium difficile strain. Infect Immun 56, 2299–2306.

    CAS  PubMed  Google Scholar 

  48. Goncalves C, Decre D, Barbut F, Burghoffer B and Petit JC. (2004) Prevalence and characterization of a binary toxin (actin-specific ADP-ribosyltransferase) from Clostridium difficile. J Clin Microbiol 42, 1933–1939.

    Article  CAS  PubMed  Google Scholar 

  49. McFarland LV. (1998) Epidemiology, risk factors and treatments for antibiotic-associated diarrhea. Dig Dis 16, 292–307.

    Article  CAS  PubMed  Google Scholar 

  50. Wilson KH, Silva J and Fekety FR. (1981) Suppression of Clostridium difficile by normal hamster cecal flora and prevention of antibiotic-associated cecitis. Infect Immun 34, 626–628.

    CAS  PubMed  Google Scholar 

  51. Onderdonk AB, Cisneros RL and Bartlett JG. (1980) Clostridium difficile in gnotobiotic mice. Infect Immun 28, 277–282.

    CAS  PubMed  Google Scholar 

  52. Borriello SP and Barclay FE. (1986) An in-vitro model of colonisation resistance to Clostridium difficile infection. J Med Microbiol 21, 299–309.

    Article  CAS  PubMed  Google Scholar 

  53. Aas J, Gessert CE and Bakken JS. (2003) Recurrent Clostridium difficile colitis: case series involving 18 patients treated with donor stool administered via a nasogastric tube. Clin Infect Dis 36, 580–585.

    Article  PubMed  Google Scholar 

  54. Tvede M and Rask-Madsen J. (1989) Bacteriotherapy for chronic relapsing Clostridium difficile diarrhoea in six patients. Lancet 1, 1156–1160.

    Article  CAS  PubMed  Google Scholar 

  55. Aronsson B, Mollby R and Nord CE. (1985) Antimicrobial agents and Clostridium difficile in acute enteric disease: epidemiological data from Sweden, 1980–1982. J Infect Dis 151, 476–481.

    Article  CAS  PubMed  Google Scholar 

  56. Larson HE, Price AB, Honour P and Borriello SP. (1978) Clostridium difficile and the aetiology of pseudomembranous colitis. Lancet 1, 1063–1066.

    Article  CAS  PubMed  Google Scholar 

  57. Nakamura S, Mikawa M, Nakashio S, et al. (1981) Isolation of Clostridium difficile from the feces and the antibody in sera of young and elderly adults. Microbiol Immunol 25, 345–351.

    CAS  PubMed  Google Scholar 

  58. Viscidi R, Willey S and Bartlett JG. (1981) Isolation rates and toxigenic potential of Clostridium difficile isolates from various patient populations. Gastroenterology 81, 5–9.

    CAS  PubMed  Google Scholar 

  59. Iizuka M, Itou H, Konno S, et al. (2004) Elemental diet modulates the growth of Clostridium difficile in the gut flora. Aliment Pharmacol Ther 20(Suppl 1), 151–157.

    Article  CAS  PubMed  Google Scholar 

  60. Brazier JS. (1998) The epidemiology and typing of Clostridium difficile. J Antimicrob Chemother 41(Suppl C), 47–57.

    Article  CAS  PubMed  Google Scholar 

  61. McFarland LV, Mulligan ME, Kwok RY and Stamm WE. (1989) Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 320, 204–210.

    Article  CAS  PubMed  Google Scholar 

  62. Bobulsky GS, Al-Nassir WN, Riggs MM, Sethi AK and Donskey CJ. (2008) Clostridium difficile skin contamination in patients with C. difficile-associated disease. Clin Infect Dis 46, 447–450.

    Article  PubMed  Google Scholar 

  63. Riggs MM, Sethi AK, Zabarsky TF, Eckstein EC, Jump RL and Donskey CJ. (2007) Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis 45, 992–998.

    Article  PubMed  Google Scholar 

  64. de Lalla F, Privitera G, Ortisi G, et al. (1989) Third generation cephalosporins as a risk factor for Clostridium difficile-associated disease: a four-year survey in a general hospital. J Antimicrob Chemother 23, 623–631.

    Article  PubMed  Google Scholar 

  65. Riley TV. (1996) Antibiotic-associated diarrhoea. A costly problem. PharmacoEconomics 10, 1–3.

    Article  CAS  PubMed  Google Scholar 

  66. Spencer RC. (1998) The role of antimicrobial agents in the aetiology of Clostridium difficile-associated disease. J Antimicrob Chemother 41(Suppl C), 21–27.

    Article  CAS  PubMed  Google Scholar 

  67. Gerding DN, Olson MM, Peterson LR, et al. (1986) Clostridium difficile-associated diarrhea and colitis in adults. A prospective case-controlled epidemiologic study. Arch Intern Med 146, 95–100.

    Article  CAS  PubMed  Google Scholar 

  68. Golledge CL, Carson CF, O’Neill GL, Bowman RA and Riley TV. (1992) Ciprofloxacin and Clostridium difficile-associated diarrhoea. J Antimicrob Chemother 30, 141–147.

    Article  CAS  PubMed  Google Scholar 

  69. Gaynes R, Rimland D, Killum E, et al. (2004) Outbreak of Clostridium difficile infection in a long-term care facility: association with gatifloxacin use. Clin Infect Dis 38, 640–645.

    Article  PubMed  Google Scholar 

  70. Khurana A, Vinayek N, Recco RA, Go ES and Zaman MM. (2004) The incidence of Clostridium difficile-associated and non-C. difficile-associated diarrhea after use of gatifloxacin and levofloxacin in an acute-care facility. Clin Infect Dis 39, 602–603.

    Article  PubMed  Google Scholar 

  71. Pepin J, Saheb N, Coulombe MA, et al. (2005) Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec. Clin Infect Dis 41, 1254–1260.

    Article  CAS  PubMed  Google Scholar 

  72. Loo VG, Poirier L, Miller MA, et al. (2005) A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med 353, 2442–2449.

    Article  CAS  PubMed  Google Scholar 

  73. McDonald LC, Killgore GE, Thompson A, et al. (2005) An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med 353, 2433–2441.

    Article  CAS  PubMed  Google Scholar 

  74. Thomas C, Stevenson M, Williamson DJ and Riley TV. (2002) Clostridium difficile-associated diarrhea: epidemiological data from Western Australia associated with a modified antibiotic policy. Clin Infect Dis 35, 1457–1462.

    Article  PubMed  Google Scholar 

  75. Karlstrom O, Fryklund B, Tullus K and Burman LG. (1998) A prospective nationwide study of Clostridium difficile-associated diarrhea in Sweden. The Swedish Clostridium difficile Study Group. Clin Infect Dis 26, 141–145.

    Article  CAS  PubMed  Google Scholar 

  76. Anand A and Glatt AE. (1993) Clostridium difficile infection associated with antineoplastic chemotherapy: a review. Clin Infect Dis 17, 109–113.

    Article  CAS  PubMed  Google Scholar 

  77. Bliss DZ, Johnson S, Savik K, Clabots CR, Willard K and Gerding DN. (1998) Acquisition of Clostridium difficile and Clostridium difficile-associated diarrhea in hospitalized patients receiving tube feeding. Ann Intern Med 129, 1012–1019.

    CAS  PubMed  Google Scholar 

  78. Dial S, Alrasadi K, Manoukian C, Huang A and Menzies D. (2004) Risk of Clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors: cohort and case-control studies. CMAJ 171, 33–38.

    Article  PubMed  Google Scholar 

  79. McFarland LV, Surawicz CM and Stamm WE. (1990) Risk factors for Clostridium difficile carriage and C. difficile-associated diarrhea in a cohort of hospitalized patients. J Infect Dis 162, 678–684.

    Article  CAS  PubMed  Google Scholar 

  80. Karlsson S, Lindberg A, Norin E, Burman LG and Åkerlund T. (2000) Toxins, butyric acid, and other short-chain fatty acids are coordinately expressed and down-regulated by cysteine in Clostridium difficile. Infect Immun 68, 5881–5888.

    Article  CAS  PubMed  Google Scholar 

  81. Wilson KH. (1993) The microecology of Clostridium difficile. Clin Infect Dis 16(Suppl 4), S214–S218.

    Article  PubMed  Google Scholar 

  82. Dallal RM, Harbrecht BG, Boujoukas AJ, et al. (2002) Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications. Ann Surg 235, 363–372.

    Article  PubMed  Google Scholar 

  83. Kuijper EJ, van Dissel JT and Wilcox MH. (2007) Clostridium difficile: changing epidemiology and new treatment options. Curr Opin Infect Dis 20, 376–383.

    PubMed  Google Scholar 

  84. Pepin J, Valiquette L, Alary ME, et al. (2004) Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity. CMAJ 171, 466–472.

    Article  PubMed  Google Scholar 

  85. Delmee M. (2001) Laboratory diagnosis of Clostridium difficile disease. Clin Microbiol Infect 7, 411–416.

    Article  CAS  PubMed  Google Scholar 

  86. Johnson S, Homann SR, Bettin KM, et al. (1992) Treatment of asymptomatic Clostridium difficile carriers (fecal excretors) with vancomycin or metronidazole. A randomized, placebo-controlled trial. Ann Intern Med 117, 297–302.

    CAS  PubMed  Google Scholar 

  87. Djuretic T, Wall PG and Brazier JS. (1999) Clostridium difficile: an update on its epidemiology and role in hospital outbreaks in England and Wales. J Hosp Infect 41, 213–218.

    Article  CAS  PubMed  Google Scholar 

  88. Mylonakis E, Ryan ET and Calderwood SB. (2001) Clostridium difficile – associated diarrhea: a review. Arch Intern Med 161, 525–533.

    Article  CAS  PubMed  Google Scholar 

  89. Barbut F, Kajzer C, Planas N and Petit JC. (1993) Comparison of three enzyme immunoassays, a cytotoxicity assay, and toxigenic culture for diagnosis of Clostridium difficile-associated diarrhea. J Clin Microbiol 31, 963–967.

    CAS  PubMed  Google Scholar 

  90. Fekety R and Shah AB. (1993) Diagnosis and treatment of Clostridium difficile colitis. J Am Med Assoc 269, 71–75.

    Article  CAS  Google Scholar 

  91. Gerding DN and Brazier JS. (1993) Optimal methods for identifying Clostridium difficile infections. Clin Infect Dis 16(Suppl 4), S439–S442.

    Article  PubMed  Google Scholar 

  92. Peterson LR, Kelly PJ and Nordbrock HA. (1996) Role of culture and toxin detection in laboratory testing for diagnosis of Clostridium difficile-associated diarrhea. Eur J Clin Microbiol Infect Dis 15, 330–336.

    Article  CAS  PubMed  Google Scholar 

  93. Bartlett JG. (2002) Clinical practice. Antibiotic-associated diarrhea. N Engl J Med 346, 334–339.

    Article  PubMed  Google Scholar 

  94. Johnson S, Kent SA, O’Leary KJ, et al. (2001) Fatal pseudomembranous colitis associated with a variant clostridium difficile strain not detected by toxin A immunoassay. Ann Intern Med 135, 434–438.

    CAS  PubMed  Google Scholar 

  95. MacCannell DR, Louie TJ, Gregson DB, et al. (2006) Molecular analysis of Clostridium difficile PCR ribotype 027 isolates from Eastern and Western Canada. J Clin Microbiol 44, 2147–2152.

    Article  CAS  PubMed  Google Scholar 

  96. Renshaw AA, Stelling JM and Doolittle MH. (1996) The lack of value of repeated Clostridium difficile cytotoxicity assays. Arch Pathol Lab Med 120, 49–52.

    CAS  PubMed  Google Scholar 

  97. Gumerlock PH, Tang YJ, Weiss JB and Silva J, Jr. (1993) Specific detection of toxigenic strains of Clostridium difficile in stool specimens. J Clin Microbiol 31, 507–511.

    CAS  PubMed  Google Scholar 

  98. Wolfhagen MJ, Fluit AC, Torensma R, Poppelier MJ and Verhoef J. (1994) Rapid detection of toxigenic Clostridium difficile in fecal samples by magnetic immuno PCR assay. J Clin Microbiol 32, 1629–1633.

    CAS  PubMed  Google Scholar 

  99. Olson MM, Shanholtzer CJ, Lee JT, Jr. and Gerding DN. (1994) Ten years of prospective Clostridium difficile-associated disease surveillance and treatment at the Minneapolis VA Medical Center, 1982–1991. Infect Control Hosp Epidemiol 15, 371–381.

    Article  CAS  PubMed  Google Scholar 

  100. Tedesco FJ, Corless JK and Brownstein RE. (1982) Rectal sparing in antibiotic-associated pseudomembranous colitis: a prospective study. Gastroenterology 83, 1259–1260.

    CAS  PubMed  Google Scholar 

  101. Bulusu M, Narayan S, Shetler K and Triadafilopoulos G. (2000) Leukocytosis as a harbinger and surrogate marker of Clostridium difficile infection in hospitalized patients with diarrhea. Am J Gastroenterol 95, 3137–3141.

    Article  CAS  PubMed  Google Scholar 

  102. Dubberke ER, Sadhu J, Gatti R, et al. (2007) Severity of Clostridium difficile-associated disease (CDAD) in allogeneic stem cell transplant recipients: evaluation of a CDAD severity grading system. Infect Control Hosp Epidemiol 28, 208–211.

    Article  PubMed  Google Scholar 

  103. Belmares J, Gerding DN, Parada JP, Miskevics S, Weaver F and Johnson S. (2007) Outcome of metronidazole therapy for Clostridium difficile disease and correlation with a scoring system. J Infect 55, 495–501.

    Article  PubMed  Google Scholar 

  104. Rubin MS, Bodenstein LE and Kent KC. (1995) Severe Clostridium difficile colitis. Dis Colon Rectum 38, 350–354.

    Article  CAS  PubMed  Google Scholar 

  105. Zar FA, Bakkanagari SR, Moorthi KM and Davis MB. (2007) A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis 45, 302–307.

    Article  CAS  PubMed  Google Scholar 

  106. Marinella MA, Burdette SD, Bedimo R and Markert RJ. (2004) Leukemoid reactions complicating colitis due to Clostridium difficile. South Med J 97, 959–963.

    Article  PubMed  Google Scholar 

  107. Byrn JC, Maun DC, Gingold DS, Baril DT, Ozao JJ and Divino CM. (2008) Predictors of mortality after colectomy for fulminant Clostridium difficile colitis. Arch Surg 143, 150–154, discussion 5.

    Article  PubMed  Google Scholar 

  108. Lamontagne F, Labbe AC, Haeck O, et al. (2007) Impact of emergency colectomy on survival of patients with fulminant Clostridium difficile colitis during an epidemic caused by a hypervirulent strain. Ann Surg 245, 267–272.

    Article  PubMed  Google Scholar 

  109. Muto CA, Pokrywka M, Shutt K, et al. (2005) A large outbreak of Clostridium difficile-associated disease with an unexpected proportion of deaths and colectomies at a teaching hospital following increased fluoroquinolone use. Infect Control Hosp Epidemiol 26, 273–280.

    Article  PubMed  Google Scholar 

  110. Pepin J, Valiquette L and Cossette B. (2005) Mortality attributable to nosocomial Clostridium difficile-associated disease during an epidemic caused by a hypervirulent strain in Quebec. CMAJ 173, 1037–1042.

    Article  PubMed  Google Scholar 

  111. Musher DM, Aslam S, Logan N, et al. (2005) Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis 40, 1586–1590.

    Article  CAS  PubMed  Google Scholar 

  112. Kuijper EJ, Coignard B and Tull P. (2006) Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect 12(Suppl 6), 2–18.

    Article  CAS  PubMed  Google Scholar 

  113. Kuijper EJ, van den Berg RJ, Debast S, et al. (2006) Clostridium difficile ribotype 027, toxinotype III, the Netherlands. Emerg Infect Dis 12, 827–830.

    Article  PubMed  Google Scholar 

  114. Warny M, Pepin J, Fang A, et al. (2005) Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet 366, 1079–1084.

    Article  CAS  PubMed  Google Scholar 

  115. Åkerlund T, Persson I, Unemo M, et al. (2008) Increased sporulation rate of epidemic Clostridium difficile Type 027/NAP1. J Clin Microbiol 46, 1530–1533.

    Article  PubMed  Google Scholar 

  116. Biller P, Shank B, Lind L, et al. (2007) Moxifloxacin therapy as a risk factor for Clostridium difficile-associated disease during an outbreak: attempts to control a new epidemic strain. Infect Control Hosp Epidemiol 28, 198–201.

    Article  PubMed  Google Scholar 

  117. Valiquette L, Cossette B, Garant MP, Diab H and Pepin J. (2007) Impact of a reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile-associated disease caused by the hypervirulent NAP1/027 strain. Clin Infect Dis 45(Suppl 2), S112–S121.

    Article  CAS  PubMed  Google Scholar 

  118. Fowler S, Webber A, Cooper BS, et al. (2007) Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a controlled interrupted time series. J Antimicrob Chemother 59, 990–995.

    Article  CAS  PubMed  Google Scholar 

  119. Bartlett JG. (1984) Treatment of antibiotic-associated pseudomembranous colitis. Rev Infect Dis 6(Suppl 1), S235–S241.

    Article  PubMed  Google Scholar 

  120. Teasley DG, Gerding DN, Olson MM, et al. (1983) Prospective randomised trial of metronidazole versus vancomycin for Clostridium difficile-associated diarrhoea and colitis. Lancet 2, 1043–1046.

    Article  CAS  PubMed  Google Scholar 

  121. Wenisch C, Parschalk B, Hasenhundl M, Hirschl AM and Graninger W. (1996) Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of Clostridium difficile-associated diarrhea. Clin Infect Dis 22, 813–818.

    Article  CAS  PubMed  Google Scholar 

  122. Wilcox MH and Spencer RC. (1992) Clostridium difficile infection: responses, relapses and re-infections. J Hosp Infect 22, 85–92.

    Article  CAS  PubMed  Google Scholar 

  123. Tedesco F, Markham R, Gurwith M, Christie D and Bartlett JG. (1978) Oral vancomycin for antibiotic-associated pseudomembranous colitis. Lancet 2, 226–228.

    Article  CAS  PubMed  Google Scholar 

  124. Fekety R, Silva J, Kauffman C, Buggy B and Deery HG. (1989) Treatment of antibiotic-associated Clostridium difficile colitis with oral vancomycin: comparison of two dosage regimens. Am J Med 86, 15–19.

    Article  CAS  PubMed  Google Scholar 

  125. Dever LL, Smith SM, Handwerger S and Eng RH. (1995) Vancomycin-dependent Enterococcus faecium isolated from stool following oral vancomycin therapy. J Clin Microbiol 33, 2770–2773.

    CAS  PubMed  Google Scholar 

  126. Gerding DN. (2000) Treatment of Clostridium difficile-associated diarrhea and colitis. Curr Top Microbiol Immunol 250, 127–139.

    CAS  PubMed  Google Scholar 

  127. Bolton RP and Culshaw MA. (1986) Faecal metronidazole concentrations during oral and intravenous therapy for antibiotic associated colitis due to Clostridium difficile. Gut 27, 1169–1172.

    Article  CAS  PubMed  Google Scholar 

  128. Molavi A, LeFrock JL and Prince RA. (1982) Metronidazole. Med Clin North Am 66, 121–133.

    CAS  PubMed  Google Scholar 

  129. Krook A, Lindstrom B, Kjellander J, Jarnerot G and Bodin L. (1981) Relation between concentrations of metronidazole and Bacteroides spp in faeces of patients with Crohn’s disease and healthy individuals. J Clin Pathol 34, 645–650.

    Article  CAS  PubMed  Google Scholar 

  130. Pelaez T, Alcala L, Alonso R, Rodriguez-Creixems M, Garcia-Lechuz JM and Bouza E. (2002) Reassessment of Clostridium difficile susceptibility to metronidazole and vancomycin. Antimicrob Agents Chemother 46, 1647–1650.

    Article  CAS  PubMed  Google Scholar 

  131. Barbut F, Decre D, Burghoffer B, et al. (1999) Antimicrobial susceptibilities and serogroups of clinical strains of Clostridium difficile isolated in France in 1991 and 1997. Antimicrob Agents Chemother 43, 2607–2611.

    CAS  PubMed  Google Scholar 

  132. Brazier JS, Fawley W, Freeman J and Wilcox MH. (2001) Reduced susceptibility of Clostridium difficile to metronidazole. J Antimicrob Chemother 48, 741–742.

    Article  CAS  PubMed  Google Scholar 

  133. Bishara J, Bloch Y, Garty M, Behor J and Samra Z. (2006) Antimicrobial resistance of Clostridium difficile isolates in a tertiary medical center, Israel. Diagn Microbiol Infect Dis 54, 141–144.

    Article  CAS  PubMed  Google Scholar 

  134. Johnson S, Sanchez JL and Gerding DN. (2000) Metronidazole resistance in Clostridium difficile. Clin Infect Dis 31, 625–626.

    Article  CAS  PubMed  Google Scholar 

  135. Wong SS, Woo PC, Luk WK and Yuen KY. (1999) Susceptibility testing of Clostridium difficile against metronidazole and vancomycin by disk diffusion and Etest. Diagn Microbiol Infect Dis 34, 1–6.

    Article  CAS  PubMed  Google Scholar 

  136. Fernandez A, Anand G and Friedenberg F. (2004) Factors associated with failure of metronidazole in Clostridium difficile-associated disease. J Clin Gastroenterol 38, 414–418.

    Article  CAS  PubMed  Google Scholar 

  137. Gerding DN. (2005) Metronidazole for Clostridium difficile-associated disease: is it okay for mom? Clin Infect Dis 40, 1598–1600.

    Article  CAS  PubMed  Google Scholar 

  138. Modena S, Gollamudi S and Friedenberg F. (2006) Continuation of antibiotics is associated with failure of metronidazole for Clostridium difficile-associated diarrhea. J Clin Gastroenterol 40, 49–54.

    Article  CAS  PubMed  Google Scholar 

  139. Leroi MJ, Siarakas S and Gottlieb T. (2002) E test susceptibility testing of nosocomial Clostridium difficile isolates against metronidazole, vancomycin, fusidic acid and the novel agents moxifloxacin, gatifloxacin, and linezolid. Eur J Clin Microbiol Infect Dis 21, 72–74.

    Article  CAS  PubMed  Google Scholar 

  140. Cronberg S, Castor B and Thoren A. (1984) Fusidic acid for the treatment of antibiotic-associated colitis induced by Clostridium difficile. Infection 12, 276–279.

    Article  CAS  PubMed  Google Scholar 

  141. Wullt M and Odenholt I. (2004) A double-blind randomized controlled trial of fusidic acid and metronidazole for treatment of an initial episode of Clostridium difficile-associated diarrhoea. J Antimicrob Chemother 54, 211–216.

    Article  CAS  PubMed  Google Scholar 

  142. Norén T, Wullt M, Åkerlund T, Bäck E, Odenholt I and Burman LG. (2006) Frequent emergence of resistance in Clostridium difficile during treatment of C. difficile-associated diarrhea with fusidic acid. Antimicrob Agents Chemother 50, 3028–3032.

    Article  PubMed  CAS  Google Scholar 

  143. Besier S, Ludwig A, Brade V and Wichelhaus TA. (2003) Molecular analysis of fusidic acid resistance in Staphylococcus aureus. Mol Microbiol 47, 463–469.

    Article  CAS  PubMed  Google Scholar 

  144. Noren T, Åkerlund T, Wullt M, Burman LG and Unemo M. (2007) Mutations in fusA associated with posttherapy fusidic acid resistance in Clostridium difficile. Antimicrob Agents Chemother 51, 1840–1843.

    Article  CAS  PubMed  Google Scholar 

  145. Buggy BP, Fekety R and Silva J, Jr. (1987) Therapy of relapsing Clostridium difficile-associated diarrhea and colitis with the combination of vancomycin and rifampin. J Clin Gastroenterol 9, 155–159.

    Article  CAS  PubMed  Google Scholar 

  146. Lagrotteria D, Holmes S, Smieja M, Smaill F and Lee C. (2006) Prospective, randomized inpatient study of oral metronidazole versus oral metronidazole and rifampin for treatment of primary episode of Clostridium difficile-associated diarrhea. Clin Infect Dis 43, 547–552.

    Article  CAS  PubMed  Google Scholar 

  147. de Lalla F, Privitera G, Rinaldi E, Ortisi G, Santoro D and Rizzardini G. (1989) Treatment of Clostridium difficile-associated disease with teicoplanin. Antimicrob Agents Chemother 33, 1125–1127.

    Article  PubMed  Google Scholar 

  148. Montecalvo MA. (2003) Ramoplanin: a novel antimicrobial agent with the potential to prevent vancomycin-resistant enterococcal infection in high-risk patients. J Antimicrob Chemother 51(Suppl 3), iii31–iii35.

    Article  CAS  PubMed  Google Scholar 

  149. Somner EA and Reynolds PE. (1990) Inhibition of peptidoglycan biosynthesis by ramoplanin. Antimicrob Agents Chemother 34, 413–419.

    Article  CAS  PubMed  Google Scholar 

  150. Cudic P, Kranz JK, Behenna DC, et al. (2002) Complexation of peptidoglycan intermediates by the lipoglycodepsipeptide antibiotic ramoplanin: minimal structural requirements for intermolecular complexation and fibril formation. Proc Natl Acad Sci USA 99, 7384–7389.

    Article  CAS  PubMed  Google Scholar 

  151. Pelaez T, Alcala L, Alonso R, et al. (2005) In vitro activity of ramoplanin against Clostridium difficile, including strains with reduced susceptibility to vancomycin or with resistance to metronidazole. Antimicrob Agents Chemother 49, 1157–1159.

    Article  CAS  PubMed  Google Scholar 

  152. Ackermann G, Loffler B, Adler D and Rodloff AC. (2004) In vitro activity of OPT-80 against Clostridium difficile. Antimicrob Agents Chemother 48, 2280–2282.

    Article  CAS  PubMed  Google Scholar 

  153. McVay CS and Rolfe RD. (2000) In vitro and in vivo activities of nitazoxanide against Clostridium difficile. Antimicrob Agents Chemother 44, 2254–2258.

    Article  CAS  PubMed  Google Scholar 

  154. Bartlett JG. (2006) New drugs for Clostridium difficile infection. Clin Infect Dis 43, 428–431.

    Article  PubMed  Google Scholar 

  155. Kelly CP. (1996) Immune response to Clostridium difficile infection. Eur J Gastroenterol Hepatol 8, 1048–1053.

    Article  CAS  PubMed  Google Scholar 

  156. Kyne L, Warny M, Qamar A and Kelly CP. (2001) Association between antibody response to toxin A and protection against recurrent Clostridium difficile diarrhoea. Lancet 357, 189–193.

    Article  CAS  PubMed  Google Scholar 

  157. Aronsson B, Granstrom M, Mollby R and Nord CE. (1985) Serum antibody response to Clostridium difficile toxins in patients with Clostridium difficile diarrhoea. Infection 13, 97–101.

    Article  CAS  PubMed  Google Scholar 

  158. Bacon AE, 3rd and Fekety R. (1994) Immunoglobulin G directed against toxins A and B of Clostridium difficile in the general population and patients with antibiotic-associated diarrhea. Diagn Microbiol Infect Dis 18, 205–209.

    Article  PubMed  Google Scholar 

  159. Beales IL. (2002) Intravenous immunoglobulin for recurrent Clostridium difficile diarrhoea. Gut 51, 456.

    Article  CAS  PubMed  Google Scholar 

  160. Salcedo J, Keates S, Pothoulakis C, et al. (1997) Intravenous immunoglobulin therapy for severe Clostridium difficile colitis. Gut 41, 366–370.

    Article  CAS  PubMed  Google Scholar 

  161. Warny M, Denie C, Delmee M and Lefebvre C. (1995) Gamma globulin administration in relapsing Clostridium difficile-induced pseudomembranous colitis with a defective antibody response to toxin A. Acta Clin Belg 50, 36–39.

    CAS  PubMed  Google Scholar 

  162. Kelly CP, Pothoulakis C, Vavva F, et al. (1996) Anti-Clostridium difficile bovine immunoglobulin concentrate inhibits cytotoxicity and enterotoxicity of C. difficile toxins. Antimicrob Agents Chemother 40, 373–379.

    CAS  PubMed  Google Scholar 

  163. Lyerly DM, Bostwick EF, Binion SB and Wilkins TD. (1991) Passive immunization of hamsters against disease caused by Clostridium difficile by use of bovine immunoglobulin G concentrate. Infect Immun 59, 2215–2218.

    CAS  PubMed  Google Scholar 

  164. Kelly CP, Chetham S, Keates S, et al. (1997) Survival of anti-Clostridium difficile bovine immunoglobulin concentrate in the human gastrointestinal tract. Antimicrob Agents Chemother 41, 236–241.

    CAS  PubMed  Google Scholar 

  165. Kim K, Pickering LK, DuPont HL, Sullivan N and Wilkins T. (1984) In vitro and in vivo neutralizing activity of human colostrum and milk against purified toxins A and B of Clostridium difficile. J Infect Dis 150, 57–62.

    Article  CAS  PubMed  Google Scholar 

  166. Aboudola S, Kotloff KL, Kyne L, et al. (2003) Clostridium difficile vaccine and serum immunoglobulin G antibody response to toxin A. Infect Immun 71, 1608–1610.

    Article  CAS  PubMed  Google Scholar 

  167. Sougioultzis S, Kyne L, Drudy D, et al. (2005) Clostridium difficile toxoid vaccine in recurrent C. difficile-associated diarrhea. Gastroenterology 128, 764–770.

    Article  PubMed  Google Scholar 

  168. Kreutzer EW and Milligan FD. (1978) Treatment of antibiotic-associated pseudomembranous colitis with cholestyramine resin. Johns Hopkins Med J 143, 67–72.

    CAS  PubMed  Google Scholar 

  169. Taylor NS, Thorne GM and Bartlett JG. (1981) Comparison of two toxins produced by Clostridium difficile. Infect Immun 34, 1036–1043.

    CAS  PubMed  Google Scholar 

  170. Louie TJ, Peppe J, Watt CK, et al. (2006) Tolevamer, a novel nonantibiotic polymer, compared with vancomycin in the treatment of mild to moderately severe Clostridium difficile-associated diarrhea. Clin Infect Dis 43, 411–420.

    Article  CAS  PubMed  Google Scholar 

  171. Joyce AM and Burns DL. (2002) Recurrent Clostridium difficile colitis. Tackling a tenacious nosocomial infection. Postgrad Med 112, 53–4, 7–8, 65 passim.

    Article  PubMed  Google Scholar 

  172. Kyne L and Kelly CP. (2001) Recurrent Clostridium difficile diarrhoea. Gut 49, 152–153.

    Article  CAS  PubMed  Google Scholar 

  173. McFarland LV, Surawicz CM, Rubin M, Fekety R, Elmer GW and Greenberg RN. (1999) Recurrent Clostridium difficile disease: epidemiology and clinical characteristics. Infect Control Hosp Epidemiol 20, 43–50.

    Article  CAS  PubMed  Google Scholar 

  174. McFarland LV, Elmer GW and Surawicz CM. (2002) Breaking the cycle: treatment strategies for 163 cases of recurrent Clostridium difficile disease. Am J Gastroenterol 97, 1769–1775.

    Article  CAS  PubMed  Google Scholar 

  175. Tedesco FJ, Gordon D and Fortson WC. (1985) Approach to patients with multiple relapses of antibiotic-associated pseudomembranous colitis. Am J Gastroenterol 80, 867–868.

    CAS  PubMed  Google Scholar 

  176. Issack MI and Elliott TS. (1990) Clostridium difficile carriage after infection. Lancet 335, 610–611.

    Article  CAS  PubMed  Google Scholar 

  177. Wilcox MH, Fawley WN, Settle CD and Davidson A. (1998) Recurrence of symptoms in Clostridium difficile infection – relapse or reinfection? J Hosp Infect 38, 93–100.

    Article  CAS  PubMed  Google Scholar 

  178. Barbut F, Richard A, Hamadi K, Chomette V, Burghoffer B and Petit JC. (2000) Epidemiology of recurrences or reinfections of Clostridium difficile-associated diarrhea. J Clin Microbiol 38, 2386–2388.

    CAS  PubMed  Google Scholar 

  179. Hamilton-Miller JM. (1997) Living in the ‘post-antibiotic era’: could the use of probiotics be an effective strategy? Clin Microbiol Infect 3, 2–3.

    Article  PubMed  Google Scholar 

  180. McFarland LV, Surawicz CM, Greenberg RN, et al. (1994) A randomized placebo-controlled trial of Saccharomyces boulardii in combination with standard antibiotics for Clostridium difficile disease. J Am Med Assoc 271, 1913–1918.

    Article  CAS  Google Scholar 

  181. Surawicz CM, McFarland LV, Greenberg RN, et al. (2000) The search for a better treatment for recurrent Clostridium difficile disease: use of high-dose vancomycin combined with Saccharomyces boulardii. Clin Infect Dis 31, 1012–1017.

    Article  CAS  PubMed  Google Scholar 

  182. Gorbach SL, Chang TW and Goldin B. (1987) Successful treatment of relapsing Clostridium difficile colitis with Lactobacillus GG. Lancet 2, 1519.

    Article  CAS  PubMed  Google Scholar 

  183. Thomas MR, Litin SC, Osmon DR, Corr AP, Weaver AL and Lohse CM. (2001) Lack of effect of Lactobacillus GG on antibiotic-associated diarrhea: a randomized, placebo-controlled trial. Mayo Clin Proc 76, 883–889.

    CAS  PubMed  Google Scholar 

  184. Orrhage K and Nord CE. (2000) Bifidobacteria and lactobacilli in human health. Drugs Exp Clin Res 26, 95–111.

    CAS  PubMed  Google Scholar 

  185. McFarland LV. (2006) Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease. Am J Gastroenterol 101, 812–822.

    Article  PubMed  Google Scholar 

  186. Kimmey MB, Elmer GW, Surawicz CM and McFarland LV. (1990) Prevention of further recurrences of Clostridium difficile colitis with Saccharomyces boulardii. Dig Dis Sci 35, 897–901.

    Article  CAS  PubMed  Google Scholar 

  187. Surawicz CM, McFarland LV, Elmer G and Chinn J. (1989) Treatment of recurrent Clostridium difficile colitis with vancomycin and Saccharomyces boulardii. Am J Gastroenterol 84, 1285–1287.

    CAS  PubMed  Google Scholar 

  188. Czerucka D and Rampal P. (2002) Experimental effects of Saccharomyces boulardii on diarrheal pathogens. Microbes Infect 4, 733–739.

    Article  PubMed  Google Scholar 

  189. Biller JA, Katz AJ, Flores AF, Buie TM and Gorbach SL. (1995) Treatment of recurrent Clostridium difficile colitis with Lactobacillus GG. J Pediatr Gastroenterol Nutr 21, 224–226.

    Article  CAS  PubMed  Google Scholar 

  190. Bowden TA, Jr., Mansberger AR, Jr. and Lykins LE. (1981) Pseudomembranous enterocolitis: mechanism for restoring floral homeostasis. Am Surg 47, 178–183.

    PubMed  Google Scholar 

  191. Schwan A, Sjolin S, Trottestam U and Aronsson B. (1983) Relapsing Clostridium difficile enterocolitis cured by rectal infusion of homologous faeces. Lancet 2, 845.

    Article  CAS  PubMed  Google Scholar 

  192. Merrigan MM, Sambol SP, Johnson S and Gerding DN. (2003) Prevention of fatal Clostridium difficile-associated disease during continuous administration of clindamycin in hamsters. J Infect Dis 188, 1922–1927.

    Article  CAS  PubMed  Google Scholar 

  193. Seal D, Borriello SP, Barclay F, Welch A, Piper M and Bonnycastle M. (1987) Treatment of relapsing Clostridium difficile diarrhoea by administration of a non-toxigenic strain. Eur J Clin Microbiol 6, 51–53.

    Article  CAS  PubMed  Google Scholar 

  194. NCCLS. (2007) Methods for Antimicrobial Susceptibility Testing of Anaerobic Bacteria; Approved Standard. In: Hecht DW, Citron DM, Cox M, et al., eds., 7th ed., NCCLS, Pennsylvania, 1–47.

    Google Scholar 

  195. Baverud V, Gunnarsson A, Karlsson M and Franklin A. (2004) Antimicrobial susceptibility of equine and environmental isolates of Clostridium difficile. Microb Drug Resist 10, 57–63.

    Article  CAS  PubMed  Google Scholar 

  196. Poilane I, Cruaud P, Torlotin JC and Collignon A. (2000) Comparison of the E test to the reference agar dilution method for antibiotic susceptibility testing of Clostridium difficile. Clin Microbiol Infect 6, 155–156.

    Article  CAS  PubMed  Google Scholar 

  197. Climo MW, Israel DS, Wong ES, Williams D, Coudron P and Markowitz SM. (1998) Hospital-wide restriction of clindamycin: effect on the incidence of Clostridium difficile-associated diarrhea and cost. Ann Intern Med 128, 989–995.

    CAS  PubMed  Google Scholar 

  198. Tang-Feldman YJ, Henderson JP, Ackermann G, et al. (2005) Prevalence of the ermB gene in Clostridium difficile strains isolated at a university teaching hospital from 1987 through 1998. Clin Infect Dis 40, 1537–1540.

    Article  CAS  PubMed  Google Scholar 

  199. Johnson S, Samore MH, Farrow KA, et al. (1999) Epidemics of diarrhea caused by a clindamycin-resistant strain of Clostridium difficile in four hospitals. N Engl J Med 341, 1645–1651.

    Article  CAS  PubMed  Google Scholar 

  200. Pituch H, Obuch-Woszczatynski P, Meisel-Mikolajczyk F and Luczak M. (2003) Detection of ermB gene responsible for high level resistance to clindamycin (MLS type resistance) among Clostridium difficile strains isolated from antibiotic associated diarrhea (AAD). Med Dosw Mikrobiol 55, 61–66.

    CAS  PubMed  Google Scholar 

  201. Linder JA, Huang ES, Steinman MA, Gonzales R and Stafford RS. (2005) Fluoroquinolone prescribing in the United States: 1995 to 2002. Am J Med 118, 259–268.

    Article  PubMed  Google Scholar 

  202. McFarland LV, Clarridge JE, Beneda HW and Raugi GJ. (2007) Fluoroquinolone use and risk factors for Clostridium difficile-associated disease within a Veterans Administration Health Care System. Clin Infect Dis 45, 1141–1151.

    Article  PubMed  Google Scholar 

  203. Pepin J, Alary ME, Valiquette L, et al. (2005) Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada. Clin Infect Dis 40, 1591–1597.

    Article  CAS  PubMed  Google Scholar 

  204. Aspevall O, Lundberg A, Burman LG, Åkerlund T and Svenungsson B. (2006) Antimicrobial susceptibility pattern of Clostridium difficile and its relation to PCR ribotypes in a Swedish University Hospital. Antimicrob Agents Chemother 50, 1890–1892.

    Article  CAS  PubMed  Google Scholar 

  205. Schmidt C, Loffler B and Ackermann G. (2007) Antimicrobial phenotypes and molecular basis in clinical strains of Clostridium difficile. Diagn Microbiol Infect Dis 59, 1–5.

    Article  CAS  PubMed  Google Scholar 

  206. Leclercq R. (2002) Mechanisms of resistance to macrolides and lincosamides: nature of the resistance elements and their clinical implications. Clin Infect Dis 34, 482–492.

    Article  CAS  PubMed  Google Scholar 

  207. Norén T, Bäck E, Alriksson I and Unemo M. (2006) New antimicrobials and resistance in C. difficile isolates and the potential risk of Clostridium difficile-associated diarrhea. 46th Interscience Conference on Antimicrobial Agents and Chemotherapy, abstract E-742.

    Google Scholar 

  208. Tabaqchali S. (1990) Epidemiologic markers of Clostridium difficile. Rev Infect Dis 12(Suppl 2), S192–S199.

    Article  CAS  PubMed  Google Scholar 

  209. Tang YJ, Houston ST, Gumerlock PH, et al. (1995) Comparison of arbitrarily primed PCR with restriction endonuclease and immunoblot analyses for typing Clostridium difficile isolates. J Clin Microbiol 33, 3169–3173.

    CAS  PubMed  Google Scholar 

  210. Wust J, Sullivan NM, Hardegger U and Wilkins TD. (1982) Investigation of an outbreak of antibiotic-associated colitis by various typing methods. J Clin Microbiol 16, 1096–1101.

    CAS  PubMed  Google Scholar 

  211. Nakamura S, Serikawa T, Mikawa M, Nakashio S, Yamakawa K and Nishida S. (1981) Agglutination, toxigenicity and sorbitol fermentation of Clostridium difficile. Microbiol Immunol 25, 863–870.

    CAS  PubMed  Google Scholar 

  212. Delmee M, Homel M and Wauters G. (1985) Serogrouping of Clostridium difficile strains by slide agglutination. J Clin Microbiol 21, 323–327.

    CAS  PubMed  Google Scholar 

  213. Mulligan ME, Peterson LR, Kwok RY, Clabots CR and Gerding DN. (1988) Immunoblots and plasmid fingerprints compared with serotyping and polyacrylamide gel electrophoresis for typing Clostridium difficile. J Clin Microbiol 26, 41–46.

    CAS  PubMed  Google Scholar 

  214. Peerbooms PG, Kuijt P and Maclaren DM. (1987) Application of chromosomal restriction endonuclease digest analysis for use as typing method for Clostridium difficile. J Clin Pathol 40, 771–776.

    Article  CAS  PubMed  Google Scholar 

  215. Wren BW and Tabaqchali S. (1987) Restriction endonuclease DNA analysis of Clostridium difficile. J Clin Microbiol 25, 2402–2404.

    CAS  PubMed  Google Scholar 

  216. Welsh J and McClelland M. (1990) Fingerprinting genomes using PCR with arbitrary primers. Nucleic Acids Res 18, 7213–7218.

    Article  CAS  PubMed  Google Scholar 

  217. Brazier JS. (2001) Typing of Clostridium difficile. Clin Microbiol Infect 7, 428–431.

    Article  CAS  PubMed  Google Scholar 

  218. Killgore GE and Kato H. (1994) Use of arbitrary primer PCR to type Clostridium difficile and comparison of results with those by immunoblot typing. J Clin Microbiol 32, 1591–1593.

    CAS  PubMed  Google Scholar 

  219. Martirosian G, Kuipers S, Verbrugh H, van Belkum A and Meisel-Mikolajczyk F. (1995) PCR ribotyping and arbitrarily primed PCR for typing strains of Clostridium difficile from a Polish maternity hospital. J Clin Microbiol 33, 2016–2021.

    CAS  PubMed  Google Scholar 

  220. Wilks M and Tabaqchali S. (1994) Typing of Clostridium difficile by polymerase chain reaction with an arbitrary primer. J Hosp Infect 28, 231–234.

    Article  CAS  PubMed  Google Scholar 

  221. Barbut F, Mario N, Delmee M, Gozian J and Petit JC. (1993) Genomic fingerprinting of Clostridium difficile isolates by using a random amplified polymorphic DNA (RAPD) assay. FEMS Microbiol Lett 114, 161–166.

    Article  CAS  PubMed  Google Scholar 

  222. Lemann F, Chambon C, Barbut F, et al. (1997) Arbitrary primed PCR rules out Clostridium difficile cross-infection among patients in a haematology unit. J Hosp Infect 35, 107–115.

    Article  CAS  PubMed  Google Scholar 

  223. Collier MC, Stock F, DeGirolami PC, Samore MH and Cartwright CP. (1996) Comparison of PCR-based approaches to molecular epidemiologic analysis of Clostridium difficile. J Clin Microbiol 34, 1153–1157.

    CAS  PubMed  Google Scholar 

  224. Gurtler V. (1993) Typing of Clostridium difficile strains by PCR-amplification of variable length 16S-23S rDNA spacer regions. J Gen Microbiol 139, 3089–3097.

    Article  CAS  PubMed  Google Scholar 

  225. Cartwright CP, Stock F, Beekmann SE, Williams EC and Gill VJ. (1995) PCR amplification of rRNA intergenic spacer regions as a method for epidemiologic typing of Clostridium difficile. J Clin Microbiol 33, 184–187.

    CAS  PubMed  Google Scholar 

  226. Al Saif NM, O’Neill GL, Magee JT, Brazier JS and Duerden BI. (1998) PCR-ribotyping and pyrolysis mass spectrometry fingerprinting of environmental and hospital isolates of Clostridium difficile. J Med Microbiol 47, 117–121.

    Article  CAS  PubMed  Google Scholar 

  227. Talon D, Bailly P, Delmee M, et al. (1995) Use of pulsed-field gel electrophoresis for investigation of an outbreak of Clostridium difficile infection among geriatric patients. Eur J Clin Microbiol Infect Dis 14, 987–993.

    Article  CAS  PubMed  Google Scholar 

  228. Bidet P, Lalande V, Salauze B, et al. (2000) Comparison of PCR-ribotyping, arbitrarily primed PCR, and pulsed-field gel electrophoresis for typing Clostridium difficile. J Clin Microbiol 38, 2484–2487.

    CAS  PubMed  Google Scholar 

  229. Kato H, Kita H, Karasawa T, et al. (2001) Colonisation and transmission of Clostridium difficile in healthy individuals examined by PCR ribotyping and pulsed-field gel electrophoresis. J Med Microbiol 50, 720–727.

    CAS  PubMed  Google Scholar 

  230. Klaassen CH, van Haren HA and Horrevorts AM. (2002) Molecular fingerprinting of Clostridium difficile isolates: pulsed-field gel electrophoresis versus amplified fragment length polymorphism. J Clin Microbiol 40, 101–104.

    Article  CAS  PubMed  Google Scholar 

  231. Kristjansson M, Samore MH, Gerding DN, et al. (1994) Comparison of restriction endonuclease analysis, ribotyping, and pulsed-field gel electrophoresis for molecular differentiation of Clostridium difficile strains. J Clin Microbiol 32, 1963–1969.

    CAS  PubMed  Google Scholar 

  232. Spigaglia P, Cardines R, Rossi S, Menozzi MG and Mastrantonio P. (2001) Molecular typing and long-term comparison of Clostridium difficile strains by pulsed-field gel electrophoresis and PCR-ribotyping. J Med Microbiol 50, 407–414.

    CAS  PubMed  Google Scholar 

  233. van Dijck P, Avesani V and Delmee M. (1996) Genotyping of outbreak-related and sporadic isolates of Clostridium difficile belonging to serogroup C. J Clin Microbiol 34, 3049–3055.

    PubMed  Google Scholar 

  234. Brazier JS, Mulligan ME, Delmee M and Tabaqchali S. (1997) Preliminary findings of the international typing study on Clostridium difficile. International Clostridium difficile Study Group. Clin Infect Dis 25 (Suppl 2), S199–S201.

    Article  PubMed  Google Scholar 

  235. Barbut F, Lalande V, Burghoffer B, Thien HV, Grimprel E and Petit JC. (2002) Prevalence and genetic characterization of toxin A variant strains of Clostridium difficile among adults and children with diarrhea in France. J Clin Microbiol 40, 2079–2083.

    Article  CAS  PubMed  Google Scholar 

  236. Rupnik M, Brazier JS, Duerden BI, Grabnar M and Stubbs SL. (2001) Comparison of toxinotyping and PCR ribotyping of Clostridium difficile strains and description of novel toxinotypes. Microbiology 147, 439–447.

    CAS  PubMed  Google Scholar 

  237. Stubbs SL, Brazier JS, O’Neill GL and Duerden BI. (1999) PCR targeted to the 16S-23S rRNA gene intergenic spacer region of Clostridium difficile and construction of a library consisting of 116 different PCR ribotypes. J Clin Microbiol 37, 461–463.

    CAS  PubMed  Google Scholar 

  238. Rupnik M, Avesani V, Janc M, von Eichel-Streiber C and Delmee M. (1998) A novel toxinotyping scheme and correlation of toxinotypes with serogroups of Clostridium difficile isolates. J Clin Microbiol 36, 2240–2247.

    CAS  PubMed  Google Scholar 

  239. Killgore G, Thompson A, Johnson S, et al. (2008) Comparison of seven techniques for typing international epidemic strains of Clostridium difficile: restriction endonuclease analysis, pulsed-field gel electrophoresis, PCR-ribotyping, multilocus sequence typing, multilocus variable-number tandem-repeat analysis, amplified fragment length polymorphism, and surface layer protein A gene sequence typing. J Clin Microbiol 46, 431–437.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Infectious Diseases, Orebro University Hospital and Orebro University, Orebro, Sweden

    Torbjörn Norén

Authors
  1. Torbjörn Norén
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Torbjörn Norén .

Editor information

Editors and Affiliations

  1. Eastman Dental Institute, Div. Microbial Diseases, University College, London, Gray's Inn Road 256, London, WC1X 8LD, United Kingdom

    Peter Mullany

  2. Eastman Dental Institute, Div. Microbial Diseases, University College, London, Gray's Inn Road 256, London, WC1X 8LD, United Kingdom

    Adam P. Roberts

Rights and permissions

Reprints and permissions

Copyright information

© 2010 Springer Science+Business Media, LLC

About this protocol

Cite this protocol

Norén, T. (2010). Clostridium difficile and the Disease It Causes. In: Mullany, P., Roberts, A. (eds) Clostridium difficile. Methods in Molecular Biology, vol 646. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-60327-365-7_2

Download citation

  • DOI: https://doi.org/10.1007/978-1-60327-365-7_2

  • Published:

  • Publisher Name: Humana Press, Totowa, NJ

  • Print ISBN: 978-1-60327-364-0

  • Online ISBN: 978-1-60327-365-7

  • eBook Packages: Springer Protocols

Publish with us

Policies and ethics

Search

Navigation